Friday, January 23, 2015

According
to the Public Health Department in the city of Ottawa, Canada, the rates of
sexually transmitted infections (STIs) such as chlamydia, gonorrhea, and HIV
are on the rise among Ottawa’s young people. In an attempt to address this, Ottawa
Public Health launched an intervention titled “Sex it Smart” (1). This program
allows Ottawa residents to order 1 package of condoms to be mailed to their
home address free of charge. The program website also contains a condom
locator, which provides the addresses of locations where residents can pick up
free condoms. This list includes health clinics, non-profit organizations, and
some private businesses. Additionally, the website contains educational
messaging around STIs. Though this intervention has many positive aspects that
increase its chances of success, including being effectively branded with a
logo, there are nonetheless aspects that need improvement.

The
“Sex It Smart” campaign homepage states, “Not using a condom is the top risk
factor among individuals diagnosed with an STI...That’s why we launched Sex It
Smart, a new condom campaign for youth.” There is also a scrolling banner at
the bottom of the homepage that states “Think of all the qualities you want in
a partner….is one of them Chlamydia?” These statements contribute to a feeling
of significant separation between the “we” behind the campaign and the “you” to
whom it is addressed that pervades the campaign’s website (1). Creating this
distinction in the campaign’s messaging could result in 2 specific negative
responses from young people when they engage with the campaign, which would
significantly decrease its chances of success.

First,
the separation between the public health workers who created the campaign and
the young people they are trying to reach could incite psychological reactance.
Psychological reactance is a phenomenon described by J.W. Brehm (2) in which
people faced with a threat to their freedom respond by immediately taking steps
to restore that freedom. A relevant example would be a parent forbidding their
teenager from attending a party, and the teenager subsequently reasserting
their freedom by sneaking out to the party that night. Studies have
demonstrated that when it comes to messages that contain a threat to freedom
(eg you must always use condoms), similarity of the messenger to the recipient
of the message can significantly decrease reactance compared to a dissimilar
messenger (3). The disparity between the messenger and the young people being
addressed in the “Sex It Smart” campaign website could result in psychological reactance
because young people will be made to feel as if their freedom to choose not to
use condoms is being threatened. This will undermine the effectiveness of the
campaign, as youth will subsequently seek to reassert their freedom to ignore
the free condoms.

Secondly,
the distanced tone of the campaign may influence youth behavior in an
unintended way through social modeling. The campaign’s homepage references the
following statistics about sexual health in Ottawa: “About a third of sexually
active 15-29 year olds in Ottawa did not use a condom the last time they had sex.
Fifteen to 29 year olds account for approximately three-quarters of 2013 chlamydia
and gonorrhea diagnoses in Ottawa” (1). Social modeling theory posits that one
way people adopt new behaviors is by mirroring behaviors observed in others in
response to certain situations (4). Because the campaign has set up a
distinction between the “us” behind the campaign and the “you” engaging with
it, emphasizing the fact that a full third of youths did not use a condom while
having sex could backfire and normalize the lack of condom use. If young people
who are interested in having sex but who are naïve or inexperienced happen upon
the site, instead of focusing on sexual health risks they may instead choose to
focus on the fact that a large number of their peers who are successfully
having sex are doing so without a condom. This in turn may influence their
decision-making when they are faced with the opportunity to have sex. If, due
to the perceived prevalence of not using a condom, they successfully have sex
without a condom for the first time, social modeling behavior theory suggests
that they will make the connection between not using a condom and effectively
having sex, and they will likely continue to abstain from condom use (4). One
examination of a failed youth-targeted anti-marijuana campaign that ran in the
United States from September 1998 to June 2004 suggests this very phenomenon as
one possibility for its failure. Hornik et al (5) state that exposure to the
campaign messaging may have inadvertently implied that marijuana use was
commonplace, thereby increasing the likelihood that young people exposed to the
campaign would try it. The “Sex It Smart” campaign runs the risk of eliciting a
similar boomerang affect by communicating to youths that many of their peers
are having sex without condoms.

Optimistic
Bias Compounded by the Power of Partner Selection

The
above statistics referenced by the “Sex It Smart” campaign do demonstrate that
there is a need to address youth sexual practices in Ottawa and attempt to
rectify the large number of young people contracting STIs. Unfortunately,
studies have demonstrated that people consistently underestimate the likelihood
of negative outcomes happening to them. This phenomenon is known as optimistic
bias, and has been demonstrated in a variety of populations, including active
smokers (6, 7). Thus even though the statistics revealing the high risk of STIs
among 15-29 year olds in Ottawa are compelling, it is likely that an individual
reading them will underestimate their own personal risk. Additionally, studies
have demonstrated that perceived controllability of a behavior increases the
optimistic bias associated with that behavior (6). In the case of STI risk,
people likely feel a large measure of control over their risk because they are
the ultimate arbiters of their own sexual experience. Feeling that they control
who their partners are will contribute to a sense of confidence that they are
at less risk than other people. When optimistic bias is taken into consideration,
the decision to highlight statistics on the homepage of the “Sex It Smart”
campaign is a strategy that has the potential to undermine the campaign. If
people don’t think that they personally are at risk, it is unlikely that they
will seek out free condoms.

The
fallacy of rational decision making in the heat of the moment

The “Sex It Smart” campaign improves upon the often-criticized
health belief model because it acknowledges that everyone does not have equal
access to condoms, and attempts to rectify that by providing them free of
charge (8). Unfortunately, the campaign ends its efforts at getting condoms
into the hands of young people, which suggests that the people who designed it believed
that once people had condoms, they would then choose use them in the moment. This
presumes that health-related decision making and behavior is the result of a
rational, considered decision-making process, an assumption which has been demonstrated
to be faulty in many situations (8). Designing the campaign to end with getting
condoms to young people reduces its chance of being successful for a few
reasons.

Firstly,
it has been demonstrated that sexual arousal significantly affects decision-making.
Especially relevant to this campaign, one study of college-aged males
demonstrated that self-reported willingness to engage in unsafe sex was
significantly higher when males were sexually aroused as compared to when they
were nonaroused. Of particular importance is that fact that subjects were
unable to predict the effect that being aroused would have on their own
tolerance for unprotected sex (9). This study indicates that even if the “Sex
It Smart” campaign were successful in getting a nonaroused person to obtain
condoms, this does not mean that in an aroused state they would use them.

Further,
a 2001 self-report study of almost 10,000 high school students across Canada
revealed that alcohol use was an independent risk factor for inconsistent
condom use (10). Alcohol has been demonstrated to affect women’s sexual
decision making by increasing their perceptions of a situation as having sexual
potential and increasing sexual interest, as well as potentially influencing
women to focus more on the positive aspect of risk-taking behavior (11). Once
again, in this context simply having condoms would not be sufficient to enable
positive behavioral change. In order to be effective, this campaign needs to
address the discrepancies between the initiative to obtain condoms and the drive
to use them in the heat of the moment.

Secondly,
the “Sex It Smart” campaign fails to address the role of gender in sexual
decision making. In her astute criticism of the health belief model, L. Thomas
decries the “…model’s inability to allow for the inclusion of the relationship
between health status and historical, social, and political structures” (12). This lack of insight into the role gender of
in sexual risk is present in the “Sex It Smart” communications. A recent study
examining 15 Australian women who engage in non-romantic sex concluded that
though these women may be partaking in “non-traditional sexual behavior,” (eg
having sex outside of a committed relationship), they were nonetheless still
constrained by traditional gender roles, and thus had limited sexual agency.
The authors suggest that this is in part due to the limited availability of a
social script that promotes empowered female sexual agency (13). These
conclusions are borne out by an evaluation of the sexual attitudes of 161 women
that demonstrated that despite initial assertiveness about condom use, even
minor prompting from a male partner against condom use substantially reduced a
woman’s likelihood to use a condom (11). In a survey of 24 English women
between the ages of 16 and 20 who were about to have or had recently had an
abortion, the women cited, among other reasons, a desire “not to break the spell”
and pressure from a male partner, as reasons why they did not use condoms (14).

When
it comes to condom use, providing women with condoms is not sufficient to
overcome the complex dynamics present in heterosexual sexual activity. These
data suggest that despite being cognizant of the risks of unprotected sex,
women often go along without using a condom, in part to please male partners.
In order to more effectively increase condom usage among young women,
initiatives need to empower women as sexual decision makers, and increase their
perceptions of self-efficacy in sexual negotiation (15). Unfortunately, the
“Sex It Smart” lacks compelling messaging addressing these issues.

Clearly,
an initiative that provides condoms with the assumption that they will be used
when young people are in the midst of a complex sexual negotiation is
erroneous. The calm, level-headed person who orders the condoms from the “Sex
It Smart” campaign website thinks differently than the aroused person who will
subsequently opt not to use them. In order to truly be effective, the “Sex It
Smart” campaign needs to take pains to go beyond providing condoms and attempt
to exert some influence over decision making during sexual activity.

Introducing We Sex It Smart – Uniting Youth for Healthier Sex

In
order to address the above flaws in the “Sex It Smart” campaign, a new campaign
called “We Sex It Smart” could utilize the existing framework of free condom
distribution but add components that would increase its chances of success. “We
Sex It Smart” would be a youth-directed movement designed by young people
themselves, and feedback from the target audience would be frequently
solicited. “We Sex It Smart” would be branded as a movement to promote better,
healthier sex, as opposed to being limited to reducing STI transmission. “We
Sex It Smart” would house personal stories on its website, highlighting people
brave enough to be open about their own experience with STIs.

To increase relevance during sexual activity, “We Sex It Smart”
would add a ritualistic component to the free condoms. Condoms would come with
stickers that could be gifted to partners or placed in sticker books that would
come with orders of condoms. There would be a variety of stickers to encourage
a “collect them all” attitude. Partners would be encouraged to create a joint
sticker book, thereby providing a level of camaraderie in sexual decision
making.

Finally, “We Sex It Smart” would host forums, discussion boards,
and branded informational material on its website that would directly address
the reality of sexual decision-making for young people. These areas would be
called “We Ladies Sex It Smart,” and “If you sip, don’t slip,” and would be
branded as distinct components of the “We Sex It Smart” campaign to increase
memorability and impact. These message boards would openly acknowledge the fact
that young people are often making sexual decisions while under the influence
of alcohol, and would allow young people to share their own experiences. There would also be educational material
addressing female sexual agency and healthy decision-making even while
drinking.

Striking the right tone for youth behavioral change

To address the issues associated with the current tone of “Sex It
Smart,” “We Sex It Smart” would engage with youths from its conception to
ensure that the tone of the campaign does not invite psychological reactance.
As demonstrated by Silvia, similarities between the messenger and the audience
reduce the risk of psychological reactance to messages that could be perceived
as limiting freedom (3). To that end, using young people themselves to
communicate the about the risk of STI transmission during unprotected sex will
decrease the chance that other young people will react negatively to the
information. Additionally, it has been demonstrated that designing public
health campaigns with youth input and featuring youth leadership is
exceptionally effective in inciting behavioral change. As described by Bauer,
the “Truth” campaign in Florida had a significant effect in reducing youth
smoking in the state. The hallmark of this campaign is that it is led by young
people and relies heavily on the input of young people who are peers of the
target audience (16). “We Sex It Smart” will borrow from this model, and
thereby seek to put youth front and center in the quest to increase healthy
sexual decision-making. The rebrand of the campaign to encompass healthy
sexuality, as opposed to simply addressing STI risk, is also an effort to
increase youth engagement. People are generally not moved by messaging and
campaigns that only focus on health. Rebranding this campaign to focus on
broader themes like autonomy, intimacy, and pleasure will help keep young
people interested and engaged (17).

Making young people the face of the “We Sex It Smart” campaign
will also address any concern with social modeling behavior. The campaign will
no longer center on unhealthy adolescent sexual behavior, but rather will
celebrate healthy sexual decisions. This will encourage youths looking to the
campaign for information on sexual behavior to associate condom use with
positive sexual outcomes (4).

Personal Stories as an Antidote to Optimistic Bias

“We Sex It Smart” will focus on the voices of young people – even
those who have made risky sexual decisions in the past. According to “the law
of small numbers,” people tend to be biased towards remembering and relating to
individual stories as opposed to broad statistics (18). Additionally, it has
been demonstrated that messages that are emotionally evocative and tell
compelling personal stories are the most impactful, and have the most potential
to incite behavioral change despite optimistic bias (19). To this end, “We Sex
It Smart” will leverage the law of small numbers by highlighting the emotionally
charged stories of people who have been affected by STIs in the past to
encourage youth to recognize that anyone can be affected by them.

Due to the sensitive nature of STI status, “We Sex It Smart” could
use the stories of adults who have since overcome their battles with STIs such
as chlamydia and gonorrhea. Adult women who have had fertility struggles due to
contracting these STIs in their youth would be particularly compelling for the
campaign. These women could share emotional stories that would drive home the
fact that despite perceived control over sexual decisions, it is impossible to
know who has an STI. It would also help dispel any stereotypes that youths have
as to who contracts STIs, as it has been demonstrated that in addition to
perceived control, an existing stereotype of who is at risk is associated with
optimistic bias (3).

Rituals and Empowerment to Encourage Relevancy in the Moment

Bridging the gap from the acquisition of condoms in a cold state
to the actual use of condoms in an aroused state is likely the biggest
challenge facing the “We Sex It Smart” campaign. This challenge is compounded
by the addition of alcohol and gender dynamics into the equation. The “We Sex
It Smart” campaign will have 2 components that will work together to attempt to
address this issue.

Firstly, the addition of a ritual can make a behavior more likely
to be adopted (18). To capitalize on this, the “We Sex It Smart” campaign will
add a ritual to condom use to make it easier to remember, even in a state of
arousal. Condoms obtained through the “We Sex It Smart” campaign will come with
stickers attached to them. These stickers will be branded to match the
campaign. The promotional messaging on the campaign website will encourage
participants to use these stickers in one of a few recommended ways: 1) post it
in public to show support for your campaign, 2) share them with friends or
partners, or 3) put them in sticker booklets that are provided with orders of
condoms. As a variety of stickers will be produced, these sticker booklets
could encourage condom usage by making a game out of collecting the stickers.
The option to choose which activity to do with your sticker would provide
another layer of ownership over the ritual, which could increase individual
investment (18). The sticker booklet will come emblazoned with promotional
messaging encouraging participants to share stickers with their partner. This
will attempt to make condom use a joint activity, which may deflect some of the
gendered tension that has been reported in heterosexual sexual activity (13-15).

Secondly, “We Sex It Smart” will add forums and informational material
that will help youth accurately address their sexual realities. For one thing,
the role of alcohol in sexual decision-making is completely absent from the
“Sex It Smart” messaging (1). “We Sex It Smart” will address alcohol as a
component of young peoples’ lives, and contextualize healthy sexual
decision-making within a social life that includes alcohol use. This aspect of
the campaign will have its own brand, called “If you sip, don’t slip.” Branding
can make a public health campaign more effective and memorable, and a critical
component of branding is to acknowledge the reality of the target audience (20).
“If you sip, don’t slip” will openly address the fact that adolescents
sometimes make sexual decisions under the influence of alcohol (10), and would
provide information on how alcohol affects sexual decision-making and
suggestions for making healthy sexual decisions even in a state of inebriation.

“We Ladies Sex It Smart” would be another branded component of the
“We Sex It Smart” campaign. This effort would focus entirely on young girls and
empowering them to have sexual agency. It would openly acknowledge that
oftentimes girls report feeling more embarrassed than boys purchasing condoms,
and this directly impacts their usage patterns (21), and also that girls react
to the influence of male partners when it comes to condom usage (11). “We
Ladies Sex It Smart” would provide empowering messages to young girls around
their ability to influence sexual decisions and speak up for their desires. It
would also provide a forum where young women could share their experiences and
encourage each other to speak up for healthy sexual experiences. This could
contribute to positive modeling behavior. If young girls are exposed to women
who have advocated for healthy sexual behavior in their own lives, it could
create new social norms that empower girls to push for condom use if they want,
even against the wishes of their male partner. Since women are reported to be
struggling from the absence of a positive social script that ascribes them
sexual agency (13), it will be up to “Ladies Sex It Smart” to create it.

Conclusion

The “Sex It Smart” campaign is strong start for an effective
public health initiative. It strives to address one of the crucial problems in
public health: access. By providing condoms to anyone in Ottawa who fills out
an online form, it makes a laudable attempt to eliminate barriers to sexual
health in a community that needs it.

Regardless, the campaign has many aspects that should be improved
to maximize its efficacy and reach. For one thing, effective public health
campaigns must work with their target audience, not speak down to them.
Harnessing the energy and voice of Canadian youth would be a boon to this
effort. Secondly, the use of statistics is not a compelling way to encourage
change. Instead, this effort should use individual stories to make its message
more relevant. Finally, the assumption that improving condom access is
sufficient to improve condom usage misses much of the reality of sexual
decision making. The addition of a fun ritual, as well as the open
acknowledgement of some of the realities of adolescent sexual life in Canada,
would make this campaign far more relevant, engaging, and effective.